| NPI | 1174151260 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: OH 34.016922) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208D00000X General Practice (Licence: WA OL61375097) | |
| Enumeration Date | 2020-04-01 |
| Last Update Date | 2025-05-04 |